title: Investment case for improving maternal and child health: results from four countries.
abstract: BACKGROUND
  Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups.
  
  
  METHODS
  The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners.
  
  
  RESULTS
  Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs.
  
  
  CONCLUSIONS
  National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.
authors.affiliation: School of Population Health, 4th Floor, Public Health Building, University of Queensland, Herston Road, Herston, QLD 4006, Australia. e.jimenez@sph.uq.edu.au
authors.forename: Eliana
authors.initials: E
authors.lastname: Jimenez Soto
authors.forename: Sophie
authors.initials: S
authors.lastname: La Vincente
authors.forename: Andrew
authors.initials: A
authors.lastname: Clark
authors.forename: Sonja
authors.initials: S
authors.lastname: Firth
authors.forename: Alison
authors.initials: A
authors.lastname: Morgan
authors.forename: Zoe
authors.initials: Z
authors.lastname: Dettrick
authors.forename: Prarthna
authors.initials: P
authors.lastname: Dayal
authors.forename: Bernardino M
authors.initials: BM
authors.lastname: Aldaba
authors.forename: Soewarta
authors.initials: S
authors.lastname: Kosen
authors.forename: Aleli D
authors.initials: AD
authors.lastname: Kraft
authors.forename: Rajashree
authors.initials: R
authors.lastname: Panicker
authors.forename: Yogendra
authors.initials: Y
authors.lastname: Prasai
authors.forename: Laksono
authors.initials: L
authors.lastname: Trisnantoro
authors.forename: Beena
authors.initials: B
authors.lastname: Varghese
authors.forename: Yulia
authors.initials: Y
authors.lastname: Widiati
mesh_terms: D002648:Child; D002662:Child Health Services / Q000191:economics*; D002669:Child Welfare / Q000706:statistics & numerical data*; D005260:Female; D015276:Health Care Rationing; D006801:Humans; D007194:India; D007214:Indonesia; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000191:economics*; D008429:Maternal Welfare / Q000706:statistics & numerical data*; D009390:Nepal; D010679:Philippines; D011247:Pregnancy; D012959:Socioeconomic Factors